Prevalence and Predictive Factors of Compassion Fatigue among Healthcare Workers in Saudi Arabia: Implications for Well-Being and Support

Compassion fatigue (CF) poses significant challenges to healthcare workers’ (HCWs) well-being. This study aimed to estimate the prevalence of CF and identify its predictive factors among HCWs in all regions of Saudi Arabia (SA). As such, all HCWs from different disciplines in different centers were allowed to participate, resulting in 678 participants. The study tool, distributed between October 2022 and January 2023, consisted of a questionnaire created by the authors based on the Professional Quality of Life Scale (ProQOL). The ProQOL measures the positive (compassion satisfaction [CS]) and negative (CF) effects of helping those who have suffered, noting that burnout (BO) and secondary traumatic stress (STS) are the two subscales that constitute CF. Our findings revealed that 63.9% of HCWs experienced average STS, while 57.2% reported average BO levels. HCWs in the southern and northern regions exhibited higher STS (p-value = 0.003 and 0.010, respectively). Physicians displayed higher BO levels (p-value = 0.024). Higher levels of CS were found among older HCWs (p-value = 0.001) and lower levels among those with more years of experience (p-value = 0.004). Support at work and job, life, and financial income satisfaction were significantly and positively correlated with CS and negatively correlated with BO and STS. These findings highlight the need for tailored awareness campaigns targeting HCWs, particularly physicians, to promote well-being, enhance coping skills, and foster problem-solving techniques. Keywords: burnout; compassion fatigue; compassion satisfaction; healthcare workers; professional quality of life; Saudi Arabia; secondary traumatic stress; medical trainees’ well-being.


Introduction
Healthcare workers (HCWs) inherently display compassion while caring for patients, which can lead to satisfaction [1]. Helping patients who are suffering (or the desire to help) might come at a high cost, however, and have significant negative consequences, including compassion fatigue (CF) [2]. CF is a work-related psychosocial consequence that may result from exposure to a cumulative level of trauma and dealing with those who have been traumatized [3]. It is associated with severe emotional distress, desensitization to patients' suffering, lack of passion for patient care, and adverse clinical outcomes [4][5][6]. quality of care and impacts the healthcare systems negatively [23][24][25]. Given the topic's significance and the limited research in SA, this study aims to determine the prevalence of CF among Saudi Arabian HCWs and explore contributing sociodemographic and workrelated factors. This research could enrich the literature and guide future interventions. We hypothesize that CF is highly prevalent among HCWs in SA and that correlations between CF and demographic and practice characteristics are likely to be found, as previously suggested in various studies in the literature.

Study Design, Setting, and Participants
A quantitative cross-sectional study was conducted among HCWs in SA. The study tool was distributed electronically among the participants between October 2022 and January 2023 via the researchers' professional networks and their social media channels, such as WhatsApp groups. The survey link was distributed online to reduce costs, to save time, and for easier geographical reach [26]. The targeted population of the study included all HCWs from all disciplines in different healthcare settings all over SA, including staff and trainees. According to the Ministry of Health, HCWs in SA are estimated to number around 485,688 [27]. Using the Raosoft sample size calculator, the required sample size was 384, with a 95% confidence interval and a margin of error of 5% [28].
This study used a convenience sampling approach. The participants in this study were grouped into (1) doctors, (2) nurses, and (3) allied HCWs. The inclusion criteria consisted of all healthcare workers (HCWs) working in different regions of Saudi Arabia (SA), including the central, eastern, western, northern, and southern areas at the time of data collection. The exclusion criteria were non-HCWs or those not working in SA at the time of data collection. The unit of analysis was the HCW.

Study Instrument
The study's instrument consisted of two parts: (1) a questionnaire developed by the research team to gather sociodemographic, occupational, and personal clinical history information and (2) the Professional Quality of Life Scale version 5 (ProQOL 5) to measure CS and CF. The following data were gathered using the questionnaire: (1) demographic data about age, gender, nationality, marital status, having children or not, and region of employment in SA; (2) personal clinical history, including having a chronic medical or mental illness; and (3) practice information, such as disciplines, departments, years of experience, hospital levels (primary, secondary, or tertiary), service type (public or private), working hours per week, the approximate number of patients treated per week, and feeling supported or not. CS and CF were measured using ProQOL 5, one of the most-used tools in studying CF [8,29]. It is a 30-item self-report scale that evaluates both positive and negative aspects of caregiving. It consists of three subscales: CS, BO, and STS, noting that BO and STS subscales constitute CF. Each of the three subscales consists of 10 items that assess how frequently in the last 30 days a respondent has experienced symptoms. Respondents rate each item on a 5-point Likert scale (1 = never to 5 = very often). Each subscale produces a score that can be classified as low, moderate, or high, with scores outside the individual range suggesting a potential risk [8]. Thorough testing has been carried out on ProQOL 5, with results indicating high levels of reliability alphas for each phenomenon; CS demonstrated a reliability alpha of 0.88, while BO and STS showed alphas of 0.75 and 0.81, respectively, and it is a valid measure of each individual phenomenon [8].

Data Analysis
Continuous variables were described using mean and standard deviation statistics, while categorical variables were described using frequencies and percentages. The normality of metric variables was assessed using the Kolmogorov-Smirnov test and histograms. The internal consistency of the questionnaire was assessed using Cronbach's alpha test. Correlations between metric variables were assessed using bivariate Pearson's correlations.
Multivariable linear regression analysis was performed to assess the association between predictor variables and the HCWs' perceptions of the CF subscale scores, expressed as beta coefficients with associated 95% confidence intervals. Statistical analysis was performed using SPSS IBM version 21 (IBM Corp., Armonk, NY, USA) with a significance level of 0.050 [30].

Results
A total of 1085 HCWs gave their consent to participate in the study. Of those, 678 completed the survey, resulting in a completion rate of 62.5%. The remaining 407 responses were deemed invalid and eliminated by the research team due to incomplete data. As the exact number of individuals who received the survey link is unknown, it is impossible to determine the response rate. Table 1 displays the resulting descriptive analysis of the HCWs' sociodemographic characteristics, professional discipline, work setting, clinical experience, and workload. Most of the sample (63.3%) were female, and 36.7% were male. Moreover, the analysis findings showed that 51% of respondents were married, 40.4% had children, and most (74.5%) were Saudi citizens. The findings also showed that 62.1% of the participants resided in the central region of Saudi Arabia. Regarding the HCWs' disciplines, 65% of them were physicians, 22.3% were nurses, and 12.7% were allied HCWs. Only a few (11.8%) had a history of psychiatric illness, and 20.2% had another chronic medical condition. The numbers of cared patients per week are shown in Figure 1. Also, the descriptive analysis for the HCWs' perceived general life and work satisfaction and perceived CF indicators are shown in Table 2.      HCWs' Satisfaction with Work and Life: The study found that the HCWs' perceived satisfaction with support at their workplace and their job satisfaction were 2.95/5 and 3.16/5, respectively. The collective mean perceived satisfaction with their personal lives was 3.18/5, while their financial income satisfaction was 3/5 on average.
Perceived Burnout Indicators among HCWs: The top perceived indicators of BO among HCWs were their feeling of being very caring people (mean = 4.02/5), their sense of happiness (mean = 3.54/5), and their feelings of connectedness to others (mean = 3.48/5). However, the lowest perceived indicators of BO were loss of productivity due to sleep deprivation as a result of traumatic stress experiences associated with people they had helped (mean = 2.11/5), their feelings of being trapped by their jobs as helpers (mean = 2.55/5), and feeling worn out because of their jobs as helpers (mean = 3.01/5). The remainder of the BO indicators were rated midway between the top and lowest perceptions of BO.
Perceived Compassion Satisfaction Indicators among HCWs: The top perceived indicators of CS among HCWs were satisfaction from helping others (mean = 4.14/5), being proud of their ability to help (mean = 4.00/5), and liking their work as helpers (mean = 3.78/5). The lowest perceived indicators of CS were feeling invigorated after working with patients (mean = 3.30/5), feeling satisfied with their work (mean = 3.47/5), and feeling pleased with keeping up with helping techniques and protocols (mean = 3.51/5).
Perceived Secondary Traumatic Stress Indicators among HCWs: HCWs' most-perceived STS indicators were having multiple patients to help (mean = 3.34/5), difficulty separating personal life from work as helpers (mean = 2.82/5), and being startled by unexpected sounds (mean = 2.66/5). The HCWs' least perceived indicators of STS were having intrusive and frightening thoughts (mean = 2.28/5), feeling as if they were experiencing others' trauma (mean = 2.32/5), avoiding situations that reminded them of trauma (mean = 2.32/5), and thinking that they might be affected by others' traumatic stress (mean = 2.34/5).   Table 4 displays the resulting bivariate correlations between the HCWs' measured perceptions of work-related CF and other factors. The findings showed that the HCWs' mean perceived BO correlated significantly, but negatively, with their mean perceived CS, r = −0.665, p-value < 0.01 (as the HCWs' mean perceived BO tended to rise, their mean perceived CS tended to decline significantly on average). Additionally, the HCWs' mean perceived STS score and their CS correlated negatively, but very weakly, r = −0.098, p-value < 0.05 (as the HCWs' mean perceived STS tended to rise, their mean perceived CS score tended to decline incrementally on average). Moreover, the HCWs' perceived support at work correlated positively and significantly with their mean perceived CS, r = 0.356, p-value < 0.010. Furthermore, their perceived job satisfaction correlated positively with their perceived CS score, r = 0.466, p-value < 0.01. In addition, their mean perceived life satisfaction and their mean perceived CS score converged significantly and positively, r = 0.403, p-value < 0.01. Nonetheless, satisfaction with financial income correlated significantly and positively with the HCWs' perceived CS score, r = 0.268, p-value < 0.01. On the other hand, the HCWs' mean perceived STS had a positive correlation with their mean perceived BO score, r = 0.445, p-value < 0.01. However, the HCWs' mean perceived support at work correlated negatively with their mean perceived BO score, r = −0.418, p-value < 0.01, and their mean job satisfaction score correlated negatively with their mean perceived BO score, r = −0.445, p-value< 0.01. The HCWs' mean perceived life satisfaction and their mean financial satisfaction scores both correlated negatively with their mean perceived BO score, p < 0.01 each. The HCWs' mean perceived received support at work score had a negative correlation with their mean STS score, r = −0.153, p-value < 0.01. Moreover, their mean perceived job satisfaction and general life satisfaction scores converged negatively on their mean perceived STS score, p-value < 0.01. In addition, the HCWs' financial satisfaction mean score had a negative correlation with their mean perceived STS score, r = −1.02, p-value < 0.01. On the other hand, the HCWs' mean perceived support at work and their mean perceived job, general life, and financial satisfaction scores all correlated significantly and positively with each other, with p-values of 0.01 each.
Multivariable linear regression analysis was applied to the HCWs' mean perceived CS score to better understand why the HCWs perceived more or less satisfaction with compassion. Table 5 presents the results. These show that HCWs aged 41 or older had a significantly higher mean perceived CS score than those aged 40 or younger. The HCWs' sex and marital status were not significantly correlated with their mean perceived CS score. However, HCWs with more than 5 years of experience had a significantly lower mean perceived CS score than those with less than 5 years of experience. The study also found that the HCWs' mean perceived job satisfaction score had a significant positive correlation with their mean perceived CS score, while their mean perceived BO score had a significant negative correlation. Moreover, the HCWs' STS score was found to have a significant positive correlation with their mean perceived CS score after accounting for other predictor variables. The results suggest that improving job satisfaction and reducing BO and STS among HCWs could enhance their perceived CS and, subsequently, improve the quality of healthcare services. Table 6 presents the results of a multivariable linear regression analysis examining the factors associated with HCWs' perceived work-related BO. The analysis found that HCWs with children had significantly lower mean perceived work-related BO scores than those without children, while physicians had significantly higher mean perceived work-related BO scores than other HCWs. The HCWs' region of residence did not significantly correlate with their perceived work-related BO score. The HCWs who worked more than 60 h per week had significantly higher mean perceived work-related BO scores than those who worked 60 h or less. In addition, the HCWs' mean perceived STS at work had correlated positively and significantly with their mean perceived work-related BO scores. In contrast, the perceived level of support at work, perceived client satisfaction at work, and general life satisfaction were all significantly negatively correlated with work-related BO scores. Finally, HCWs with a history of mental illness had significantly higher perceived work-related BO scores than those without such a history.  Table 7 presents the results of the multivariable linear regression analysis for the mean perceived STS score among HCWs in SA. The analysis revealed that HCWs' sex, age, having children, and marital status did not significantly correlate with their mean perceived STS score (p-value > 0.050). However, HCWs residing in the southern and northern regions of SA had significantly higher mean perceived STS scores than those residing in other regions (p-value = 0.003 and p-value = 0.010, respectively).
In addition, HCWs' mean perceived STS score had a positive correlation with their mean perceived CS score (beta coefficient = 0.368, p-value < 0.001), indicating that as their CS score increased, their predicted mean perceived STS score also tended to increase. Furthermore, the HCWs' mean perceived work-related BO score had a positive correlation with their mean perceived STS score (beta coefficient = 1.063, p-value < 0.001), suggesting that higher BO perception among HCWs predicted significantly higher perceived STS on average.

Discussion
This is the first study to estimate the prevalence of CF and its associated factors that includes HCWs of all disciplines in SA. Our results indicated that more than half of the HCWs had average levels of STS, with only 2.2% of the participants having high STS. These results are aligned with previous studies [22,31] which reported average STS levels. Moreover, in our results, HCWs in both southern and northern SA perceived considerably greater STS. The reason for this finding might be that the southern and northern provinces of the country are proximate to war zones, which could increase the risk of exposure to more patient-related traumatic experiences.
Surprisingly, our results showed a positive correlation between CS and STS, which is inconsistent with a study on critical care nurses in Iran that found a negative association between CS and STS [17]. A possible explanation of our finding is that the satisfaction gained from helping others reflects high interest and care, resulting in more stress. Moreover, the results from our research demonstrated that greater STS correlates with increased levels of BO, which is consistent with a systematic review conducted to evaluate the impact of the COVID-19 pandemic on CF [18].
As identified in a study conducted on therapists in the UK (n = 253, who worked in trauma services, secondary-care services, or other services), our data show that HCWs who perceive that they receive more support at work have high CS [32]. Specifically, the bivariate Pearson's correlations in our study indicated that HCWs' perceived support at work correlated positively and significantly with their mean perceived CS. These findings imply that access to support may be essential to overcoming the stressful aspects of day-today work.
In our study, CS was significantly correlated with age, with people aged 41 years and older having greater CS. Once more, these results align with a recent study's findings [33]. One explanation that we hypothesize for this result is that the older providers have developed the skills to cope with work demands. Furthermore, independent of clinical experience, maturity and life experience have predicted CS in the literature [32]. However, our research found that years of expertise negatively affected CS: HCWs with 5 or more years of experience had lower CS scores. This is in contrast to the findings of a study which indicated that increased years in the profession were associated with high CS [34]. We hypothesize that our findings concerning the years of expertise could be due to the growing duties and responsibilities that come with more years of experience.
Despite none of the participants having high BO in our study, about half reported an average level of BO, which could be worrisome. These levels are consistent with other studies, which have mainly reported moderate levels of BO [34][35][36]. Interestingly, in our study, gender was not a risk factor for BO, which is inconsistent with research conducted to examine job-related BO among 104 emergency physicians and nurses in Dammam City, SA that reported increased BO in male participants [21]. On the other hand, another study conducted in SA revealed that female psychiatrists and psychiatric trainees scored higher in the BO domain than their male colleagues [22]. These differences in findings could be due to differences in the targeted population (for example, different specialties). Moreover, female psychiatrists have long faced profession-related challenges such as inflexible career structure and being unequally represented compared to their male colleagues [37].
In our results, having children was a protective factor against BO, which is consistent with the results of a study conducted among Israeli burn clinicians that showed that having children decreased the risk of BO and CF, as they may provide emotional support and diversion from work-related stressors [38]. Our study found that physicians were more prone to score higher on the BO domain than other HCWs. Data in the literature are inconsistent regarding the association between BO and the discipline, however. For instance, in a systematic review and meta-analysis exploring BO among different disciplines, no correlation was found between BO and specific disciplines [35]. On the other hand, a study conducted in the US on 764 HCWs found that psychologists and social workers had higher BO than other healthcare providers. As the authors explained, their results could be attributed to psychologists and social workers experiencing more workplace violence [39]. In addition, our figures showed that practitioners with longer working hours (≥61 h/week) had higher BO scores than those with fewer working hours. This finding was consistent with another study conducted in the US targeting nurses working in Texas [34]. We hypothesize that this result could be related to the fact that the more hours that are spent at work, the fewer hours that are available for sleep, leading to sleep deprivation and difficulty achieving a work-life balance. Finally, similarly to previous studies [17,22], our data showed that BO in HCWs correlated negatively with their CS. It might be that increased negative emotions can affect HCWs' sense of efficacy and thus limit their experience of CS [40].
This research has particular strengths and limitations. Strength-wise, the study addresses a topic that has not been sufficiently studied in SA. Another strength is that the sample was large. A third is that the study was conducted at a national level, including HCWs of all disciplines, including trainees. A fourth strength is that the study used a well-recognized validated scale, namely ProQOL 5.
The study also has certain limitations. First, the study was of a cross-sectional design with a convenience sampling method. Second, as the targeted population included all HCWs, we were limited in obtaining responses from certain groups, such as social workers, as they are primarily Arabic speakers. Future studies with more rigorous research designs and targeting non-English-speaking HCWs (e.g., by using an Arabic questionnaire/scale) are therefore warranted. Lastly, as our study lacks data on the number of hospitals and their respective regions where the participants worked, future studies could provide insights into the representativeness of the sample across different hospitals.
Given the topic's significance and its associated negative impact that can lead to severe psychological consequences, including anxiety, depressive symptoms, and substance abuse [41], the research team recommends conducting more comprehensive awareness campaigns so that HCWs become more aware of-and informed about-programs and resources that could help them develop better-coping skills and problem-solving techniques. Hence, identifying such resources to whom HCWs can reach out is critical. It is also worth mentioning that self-care is supported as a preventative strategy for work-related stress and BO. Aspects of self-care involving flexibility, physical health, social support, and spiritual practice can help prevent negative consequences and promote well-being [42]. Evidencebased tools are also needed when assessing and treating CF-related symptoms, such as ProQOL 5, Maslach Burnout Inventory and Self-Care Behavior Inventory [41]. Notably, mindfulness, cognitive behavioral therapy, and acceptance and commitment therapy have strong evidence to alleviate such symptoms [41].

Conclusions
This study aimed to examine the prevalence of CF and its predictive factors among HCWs in SA, which could subsequently aid in promoting a healthier environment for them inside and outside work. The results, including the significant positive correlation between BO and STS and the finding that physicians were more prone to BO than other HCWs, indicate the need for more preventive interventions and awareness campaigns aiming to support HCWs in general, and physicians in particular, to minimize their risk of developing BO and STS and increase their chance of experiencing CS.